LUMBAR DISC HERNIATION AND ITS PHYSIOTHERAPY REHABILITATION

What is Herniated Disc?

Each disc of the spine is designed much like a jelly donuts. As the disc degenerates from age or injury, the softer central portion can rupture (herniate) through the surrounding outer ring (annulus fibrosus). This abnormal rupture of the central portion of the disc is referred to as a disc herniation. This is commonly referred to as a "slipped disc."

The most common location for a herniated disc to occur is in the disc at the level between the fourth and fifth lumber vertebrae.The lower back is also critically involved in our body's movements throughout the day, as we twist the torso in rotating side to side and as we hinge the back in flexion and extension while bending or lifting. Sometimes people are telling as "muscle catch" or there was  a sound like "click". So therapists or doctors only can clearly diagnose the condition through a lot of investigations

                                                            Symptoms

The symptoms of a herniated disc depend on the exact level of the spine where the disc herniation occurs and whether or not nerve tissue is being irritated. Disc herniation can cause local pain at the level of the spine affected.

If the disc herniation is large enough, the disc tissue can press on the adjacent spinal nerves that exit the spine at the level of the disc herniation. This can cause shooting pain in the distribution of that nerve and usually occurs on one side of the body and is referred to as Sciatica. For example, a disc herniation at the level between the fourth and fifth lumbar vertebrae of the low back can cause a shooting pain down the buttock into the back of the thigh and down the leg. Sometimes this is associated with numbness, weakness, and tingling in the leg. The pain often is worsened upon standing and decreases with lying down. This is often referred as pinched nerve

If the disc herniation occurs in the cervical spine, the pain may shoot down one arm and cause a stiff neck or muscle spasm in the neck.

If the disc herniation is extremely large, it can press on spinal nerves on both sides of the body. This can result in severe pain down one or both lower extremities. There can be marked muscle weakness of the lower extremities and even incontinence of bowel and bladder. This complication is medically referred to as cauda equina syndrome.

Special Investigations for Lumbar disc herniation:

Usually we are looking for, how orthopaedicians or therapists diagnose the condition through their knowledge, without using special equipment. They are using some physical examination, patient history, on time examination, special tests etc .. to find out the condition. After that they are confirming through special investigations by use of special equipment( MRI,CT,X RAY, Etc). Here I gonna discuss about some physical examinations, usually they are using to rule out the condition.

Straight Leg Raise (SLR);  
The patient is in supine position and the examiner raises the leg (on the symptomatic side). The knee stays fully extended. When the angle at the hip in which the SLR is reached differs in comparison to the other leg, or when pain is produced during the test, the test is considered to be positive.

Slump test: the sitting patient (with convex back) bends his head forward and stretches his leg out with the toes pointing upward. The purpose is to stretch the neural structures within the vertebral canal and foramen. If the pain is reappear, test is positive

Lasègue’s test: it’s an extension of the SLR: the therapist lowers the leg to an extent of five to ten degrees. Then, the foot is passively dorsiflexed. The test is considered to be positive when the ipsilateral leg pain (sciatica below the knee) occurs upon elevation.

Crossed Lasegue test (XSLR): This test is considered to be positive when the pain (sciatica) can be reproduced upon passive extension of the contra-lateral leg.

Scoliosis: the therapist is going to evaluate this parameter using visual inspection. Scoliosis might be a potential indicator of lumbar disc herniation. Research has proven that the diagnostic performance of this test is really poor. The sensitivity and specificity are really low.

Muscle weakness or paresis: the examiner measures strength during ankle dorsiflexion or extension of the big toe (without or against resistance). 
Dorsal flexion impaired --> L4 radiculopathy
Toe extension impaired --> L5 radiculopathy
If the possible range at the symptomatic side differs from the non-symptomatic side, then the test is considered to be positive.

Reflexes: weakness or absence of the Achilles tendon reflex possibly refers to S1 radiculopathy.

Forward flexion test: the purpose is to bend forward in standing position. There is no consensus regarding the criteria that have to be considered in order to determine if the radiant pain is caused by disc herniation. Some studies use limitation of forward flexion as main criteria, while others use back/leg pain as the primary indicator.

Hyper extension test: the patient needs to passively mobilize the trunk over the full range of extension, while the knees stay extended. The test indicates that the radiant pain is caused by disc herniation if the pain deteriorates.

Manual testing and sensory testing: looks for hypoaesthesia, hypoalgesia, tingling or numbness. One example of testing: the patient closes his eyes and the examiner strikes the skin bilaterally and simultaneously. The patient is asked if he feels any differences between the left and right side. The test is considered to be positive when there is a dermatomal distribution. Although, the diagnostic performance of sensitivity and specificity is poor. 

                       Physiotherapy Intervention:

Physiotherapists can help in you in lot ways to recover from the back pain by doing some of their therapies like Shock wave, Ultrasound, TENS, and IFT etc ,as well as by their special manipulation and particular exercises for this herniated disc. PT may include deep tissue massage, hot/cold therapies, hydrotherapy, and exercise. Physical therapy often plays a major role in herniated disc recovery. Its methods not only offer immediate pain relief, but they also teach you how to condition your body to prevent further injury

Stretching: There is low-quality evidence found to suggest that adding hyper extension to an intensive exercise program might not be more effective than intensive exercise alone for functional status or pain outcomes. There were also no clinically relevant or statistically significant differences found in disability and pain between combined strength training and stretching, and strength training alone.

Behavioral graded activity program: A global perceived recovery was better after a standard physiotherapy program than after a behavioral graded activity program in the short term, however no differences were noted in the long term.

Ultrasound and shock wave therapies: Ultrasound is used to penetrate the tissues and transmitting heat deep into the tissues. The aim of ultrasound is to increase local metabolism and blood circulation, enhance the flexibility of connective tissue, and accelerate tissue regeneration, potentially reducing pain and stiffness, while improving mobility. Shock wave applies vibration at a low frequency to the tissues (10, 50, 100, or 250 Hz). This causes an oscillatory pressure to decrease pain. The available evidence does not support the effectiveness of both therapy strategies for treating disc herniation.

Transcutaneous electrical nerve stimulation (TENS): TENS uses an electrical current to stimulate the patients muscles. Electrodes on the skin send a tiny electrical current to key points on the nerve pathway. It is generally believed to trigger the release of endorphins, which are the body's natural pain killers and reduce muscle spasms. For this reason, TENS therapy contribute to pain relief and improvement of function and mobility of the lumbosacral spine.

Manipulative treatment: Manipulative treatment on lumbar disc herniation appears to be safe, effective, and it seems to be better than other therapies. However high-quality evidence is needed to be further investigated.

Core strengthening exercises: A strong core is important to the health of the spine. The core (abdominal) muscles help the back muscles support the spine. When your core muscles are weak, it puts extra pressure on your back muscles. So it is important to teach core stabilizing exercises to strengthen your back. It is also very important to train the endurance of these muscles. A core stability program decreases pain level, improves functional status, increases health-related quality of life and static endurance of trunk muscles in lumbar disc herniation patients. Individual high-quality trials found moderate evidence that stabilisation exercises are more effective than no treatment.